Neurosurgery Flashcards
A 78 year old man is brought to the emergency department by the police. He is found wandering around the town centre and is confused. His family report that he is usually well apart from a simple mechanical fall 3 weeks previously from which he sustained no obvious injuries. What is the most likely underlying cause?
Acute extra dural haematoma Chronic sub dural haematoma Sub arachnoid haemorrhage Intraventricular haemorrhage Acute sub dural haematoma
The injuries that are responsible for chronic sub dural haematomas are usually fairly trivial and forgotten by the patient and their families. The onset of symptoms can be insidious with vague symptomatology and confusion predominating.
A 21 year old man is involved in a road traffic accident. After a transient period of concussion he is found to have a GCS of 15 by the paramedics. On arrival at hospital he is monitored in a side room of the emergency department. When he is next observed he is noted to have a GCS of 3 and a blown right pupil. Which of the processes below best accounts for this deterioration?
Hydrocephalus Intraventricular bleed Sub dural bleed Trans tentorial herniation Sub arachnoid haemorrhage
The presence of a blown right pupil is a sign of a third cranial nerve compression. The most likely cause is an extradural bleed. However, since this option is not listed the process of trans tentorial herniation would be the most applicable answer. Intraventricular bleeds are typically more common in premature neonates, deterioration due to hydrocephalus is more chronic.
A 28 year old man is playing tennis when he suddenly collapses and has a GCS of 4 when examined. What is the most likely cause?
Intraventricular haemorrhage Acute sub dural haematoma Sub arachnoid haemorrhage Chronic sub dural haematoma Acute extra dural haematoma
A sudden collapse and loss of consciousness is most likely to be due to a sub arachnoid haemorrhage. The other potential causes in the list usually occur as a sequel to a traumatic event, which has not occurred here
A 53 year old teacher is admitted to the vascular ward for a carotid endarterectomy. Your FY1 does a preoperative assessment and notes that there is a right homonymous hemianopia. There is no other neurology. What is the most likely cause?
Lateral medullary syndrome Middle cerebral artery infarct Anterior cerebral artery infarct Cerebellar infarct Posterior cerebral artery infarct
This patient has had a left occipital infarct, as there is only a homonymous hemianopia. If this patient had a temporal or parietal lobe infarct, there would be associated hemiparesis and higher cortical dysfunction. This is important to differentiate, as the carotid endarterectomy is inappropriate in this patient as the lesion is in the posterior cerebral artery.
A 20 year old man is admitted to the intensive care unit with an isolated severe head injury. A CT scan shows multiple intracerebral bleeds but no midline shift. He is intubated and ventilated. His pupils are dilated and react sluggishly to light. His heart rate is 50 beats/minute blood pressure 170,110 mmHg and his respiratory rate is set at 10 breaths/minute. The rising blood pressure is likely to be caused by:
Aortic and carotid baroreceptor stimulation Cortisol stimulation Renin angiotensin stimulation Sympathetic stimulation related to blood loss sympathetic stimulation related to increased intra cranial pressure
The changes seen are the result of raised ICP, its rare for head injuries to cause sufficient blood loss to affect the circulating volume.
A 25 year old cyclist is hit by a bus traveling at 30mph. He was not wearing a helmet. He arrives with a GCS of 3/15 and is intubated. A CT scan shows evidence of cerebral contusion but no localising clinical signs are present. What is the most appropriate course of action?
Burr hole decompression Decompressive craniotomy Insertion of intra cranial pressure monitoring device Administration of intravenous mannitol Parietotemporal craniotomy
This patient may well develop raised ICP over the next few days and intracranial pressure monitoring will help with management.
A 65 year old man presents with a new onset left sided hemiparesis. A CT scan of the brain is performed and this demonstrates a 4cm lesion within the right frontal lobe, it traverses the midline and displays marked central necrosis. There is extensive oedema surrounding the lesion. What is the most likely diagnosis?
Meningioma Central neurocytoma Ependymoma Oligodendroglioma Glioblastoma
Glioblastomas typically display such marked appearances and an important differential on imaging is one of cerebral abscess. A meningioma would not display such infiltrative behavior. Significant necrosis is more commonly seen with glioblastomas than with other CNS tumours.
What type of visual field defect is most likely to be noted in a patient with a craniopharyngioma?
Lower bitemporal hemianopia Upper bitemporal hemianopia Right superior quadranopia Right homonymous hemianopia Left homonymous hemianopia
Lesions at the optic chiasm classically produce a bitemporal hemianopia, however note lesions that spread up from below ie pituitary tumours, the defect is worse in the upper fields and if a lesion spreads down from above ie craniopharyngiomas, the visual defect is worse in the lower quadrants. Therefore this patient is likely to have a lower bitemporal hemianopia.
A 52 year man is admitted to the vascular ward for an amputation. The patient complains of unsteadiness. On further examination you detect right facial numbness and right sided nystagmus. There is sensory loss of the left side of the body. What is the most likely lesion?
Lateral medullary syndrome Posterior cerebral artery infarct Pontine infarct Lacunar infarct Anterior cerebral artery infarct
Lateral medullary syndrome
A combination of ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss indicates this diagnosis.
A 18 year old boy falls off a balcony and hits the right side of the head. He is admitted to the emergency department and has a GCS of 10. He is admitted for observation, and over the following twelve hours develops an increasing headache and confusion. A CT scan shows a crescent shaped collection of fluid between the brain and the dura with associated midline shift. What is the most likely diagnosis?
Acute sub dural haematoma Chronic sub dural haematoma Acute extra dural haematoma Chronic extra dural haematoma Sub arachnoid haemorrhage
Sub dural haematomas are the commonest intracranial mass lesions resulting from trauma. They are classified as acute, sub acute or chronic according to tempo of onset. Acute sub dural haematomas will present within 72 hours of the original injury and have hyperdense, crescent shaped appearances on CT scanning.
A 53 year old teacher is admitted to the vascular ward for a carotid endarterectomy. Your F1 does a preoperative assessment and notes that there is a right homonymous hemianopia. There is no other neurology. What is the most likely cause?
Middle cerebral artery infarct Lateral medullary syndrome Posterior cerebral artery infarct Lacunar infarct Anterior cerebral artery infarct
This patient has had a left occipital infarct, as there is only a homonymous hemianopia. If this patient had a temporal or parietal lobe infarct, there would be associated hemiparesis and higher cortical dysfunction. This is important to differentiate, as carotid endarterectomy is inappropriate in this patient since the lesion is in the posterior cerebral artery.
A male infant is born at 28 weeks gestation by emergency cesarean section. He is taken to theatre for a colostomy due to an imperforate anus. He initially seems to be progressing well. However, he begins to develop decerebrate posturing and is becoming increasingly obtunded. What is the most likely underlying problem?
Extra dural haematoma Sub arachnoid haemorrhage Acute sub dural haemorrhage Intraventricular haemorrhage Chronic sub dural haematoma
Acute neurological deterioration in premature neonates is usually due to intraventricular haemorrhage. Diagnosis is made by cranial ultrasound. Development of hydrocephalus may necessitate surgery.
A 33 year old lady develops a thunderclap headache and collapses. A CT scan shows that she has developed a subarachnoid haemorrhage. She currently has no evidence of raised intracranial pressure. Which of the following drugs should be administered?
None Atenotol Labetolol Nimodipine Mannitol
Nimodipine is a calcium channel blocker. It reduces cerebral vasospasm and improves outcomes. It is administered to most cases of sub arachnoid haemorrhage.
A 2 day old premature neonate is born by emergency cesarean section for maternal illness. The baby is noted to become floppy and unresponsive. What is the most likely cause?
Intraventricular haemorrhage Sub arachnoid haemorrhage Acute sub dural haematoma Acute extra dural haemhorrage Chronic sub dural haematoma
Neonatal deterioration in premature babies is not infrequently due to intra ventricular haemorrhage. In extreme prematurity the prognosis can be very poor.
A 65 year old male with known nasopharyngeal carcinoma presents with double vision over a few weeks. On examination he is found to have left eye proptosis and it is down and out. He reports pain on attempting to move the eye. There is an absent corneal reflex. What is the most likely diagnosis?
Posterior communicating artery aneurysm Cavernous sinus syndrome Optic nerve tumour Migraine Cerebral metastases
Cavernous sinus syndrome is most commonly caused by cavernous sinus tumours. In this case, the nasopharyngeal malignancy has locally invaded the left cavernous sinus. Diagnosis is based on signs of pain, opthalmoplegia, proptosis, trigeminal nerve lesion (opthalmic branch) and Horner’s syndrome.
A baby is brought to casualty unconscious and in a vegetative state. She has cigarette burns on her legs. What is the most likely underlying injury?
Acute sub dural haematoma Chronic sub dural haematoma Acute extra dural haematoma Diffuse axonal injury Sub arachnoid haemorrhage
The baby is likely to be a victim of shaken baby syndrome. This may result in diffuse axonal injury causing extensive lesions in the white matter.
A patient is referred due to the development of a third nerve palsy associated with a headache. On examination, meningism is present. Which one of the following diagnoses needs to be urgently excluded?
Weber's syndrome Internal carotid artery aneurysm Multiple sclerosis Posterior communicating artery aneurysm Anterior communicating artery aneurysm
Given the combination of a headache and third nerve palsy it is important to exclude a posterior communicating artery aneurysm
Painful third nerve palsy = posterior communicating artery aneurysm
A 53 year old man is admitted to the vascular ward for a carotid endarterectomy. His CT head report confirms a left parietal lobe infarct. What type of visual field defect might be noted?
Right inferior quadranopia Right superior quadranopia Right homonymous hemianopia Left superior quadranopia Lower bitemporal hemianopia
Superior quadranopia = temporal lobe lesion
Inferior quadranopia = parietal lobe lesion
Parietal lesions cause a contralateral inferior quadranopia.
A 52 year man is admitted to the vascular ward for an amputation. The patient complains of unsteadiness. On further examination you detect right facial numbness and right sided nystagmus. There is sensory loss of the left side of the body. What is the most likely cause?
Lateral medullary syndrome Pontine infarct Cerebellar infarct Middle cerebral artery infarct Posterior cerebral artery infarct
A combination of ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss indicates this diagnosis.
A 32 year old rugby player is crushed in a scrum. He is briefly concussed but then regains consciousness. He then collapses and is brought to ED. His GCS on arrival is 6/15 and his left pupil is dilated. What is the best course of definitive management?
Burr Hole decompression Parietotemporal craniotomy Intravenous mannitol Posterior fossa craniotomy Insertion of intra cranial pressure bolt monitor
This man needs urgent decompression and extradural haematoma is the most likely event, from a lacerated middle meningeal artery. Most neurosurgeons would perform a craniotomy. However, rural units and those units without neurosurgical kit facing this emergency may resort to Burr Holes.
A 23 year old man was driving a car at high speed whilst intoxicated, he was wearing a seat belt. The car collides with a brick wall at around 140km/h. When he arrives in the emergency department he is comatose. His CT scan appears to be normal. He remains in a persistent vegetative state. What is the most likely underlying cause?
Extradural haemorrhage Sub dural haemorrhage Sub arachnoid haemorrhage Intracerebral haemorrhage Diffuse axonal injury
Diffuse axonal injury occurs when the head is rapidly accelerated or decelerated. There are 2 components:
- Multiple haemorrhages
- Diffuse axonal damage in the white matter
Up to 2/3 occur at the junction of grey/white matter due to the different densities of the tissue. The changes are mainly histological and axonal damage is secondary to biochemical cascades. Often there are no signs of a fracture or contusion.
A middle aged lady is brought to the clinic by her husband who has noted a change in her appearance. She finds removal of rings difficult, her shoe size has changed and photographs show a marked change in her appearance. Which of the following is most likely to be identified on neurological examination?
Bi nasal hemianopia Bi temporal hemianopia Inferior quadrantanopia Homonymous hemianopia Unilateral loss of vision
The patient is most likely to have developed acromegaly. Since a pituitary lesion is likely to be present; compression of the optic chiasm may occur.
A 42 year old woman is admitted to the vascular ward for an endarterectomy. Her CT report confirms a left temporal lobe infarct. What is the most likely visual defect to be encountered?
Right homonymous hemianopia Right superior quadranopia Right inferior quadranopia Left superior quadranopia Left homonymous hemianopia
Temporal lesions cause a contralateral superior quadranopia. Think temporal area is at the top of the head i.e. superior quadranopia.
A 48 year old type 2 diabetic complains of numbness in his left arm and leg. Otherwise there are no other neurological signs. What is the most likely cause?
Middle cerebral artery infarct Lacunar infarct Pontine infarct Anterior cerebral artery infarct Posterior cerebral artery infarct
Isolated hemisensory loss is a feature of a lacunar infarct.
A 50 year old lady is admitted having fallen down some stairs sustaining multiple rib fractures 36 hours previously. On examination, she is confused and agitated and has clinical evidence of lateralising signs. She deteriorates further and then dies with no response to resuscitation. What is the most likely explanation?
Intraventricular haemorrhage Acute sub dural haemorrhage Chronic sub dural haematoma Sub arachnoid haemorrhage Extra dural haematoma
The time frame of deterioration of an acute sub dural bleed would fit with this scenario. They are highly lethal and not uncommon injuries. As the bleed enlarges, lateralising signs may be seen and eventually coning and death will occur.
A 2 year old boy presents with vague neurological symptoms and is imaged with an MRI of the brain. This demonstrates a tumour that is located in the floor of the 4th ventricle and extends through the foramen of Magendie. What is the most likely diagnosis?
Glioblastoma CNS lymphoma Ependymoma Schwannoma Meningioma
Glioblastoma is rare in children. Ependymoma account for up to 33% of CNS tumours in those under age of 3. They commonly arise in the 4th ventricle and can grow through the foramina of Luschka and Magendie
A 25-year-old female with a history of bilateral vitreous haemorrhage is referred with bilateral lesions in the cerebellar region. What is the likely diagnosis?
Neurofibromatosis type I Neurofibromatosis type II Tuberous sclerosis Von Hippel-Lindau syndrome Sarcoidosis
Retinal and cerebellar haemangiomas are key features of Von Hippel-Lindau syndrome. Retinal haemangiomas are bilateral in 25% of patients and may lead to vitreous haemorrhage
A 30 year old woman is injured in a skiing accident. She suffers a blow to the occiput and is concussed for 5 minutes. On arrival in ED she is confused with GCS 10/15. A CT scan shows no evidence of acute bleed or fracture but some evidence of oedema with the beginnings of mass effect. What is the best course of action?
Administration of intravenous mannitol Administration of intravenous frusemide Parietotemporal craniotomy Posterior fossa craniotomy Burr hold decompression
This woman has raised ICP and mannitol will help reduce this in the acute phase.
A 28 year old man falls and hits his head against a wall. There is a brief loss of consciousness. When assessed in accident and emergency he is alert and orientated with a GCS of 15, imaging shows no fracture of the skull. What is his risk of having an intracranial haematoma requiring removal?
1 in 6000 1 in 40 1 in 4 1 in 50,000 1 in 120
Risk of haematoma (requiring removal) in adults attending accident and emergency units following head injury.
Injury Conscious level Risk of haematoma requiring removal
Concussion, no skull fracture Orientated 1 in 6000
Concussion, no skull fracture Not orientated 1 in 120
Skull fracture Orientated 1 in 32
Skull fracture Not orientated 1 in 4
A 50 year old alcoholic man attends the emergency department. His main reason for presenting is that he has no home to go to. On examination, he has no evidence of involvement in recent trauma, a skull x-ray fails to show any evidence of skull fracture. He is admitted and twelve hours following admission he develops sudden onset headache, becomes comatose and then dies. What is the most likely cause?
Acute extra dural haematoma Chronic sub dural haematoma Sub arachnoid haemorrhage Intraventricular haemorrhage Acute sub dural haematoma
The absence of trauma here makes an acute sub dural and extra dural bleed unlikely. Chronic sub dural bleeds would usually cause a more gradual deterioration than is seen here. The absence of any skull fracture also makes an underlying intra cranial bleed less likely. Sudden onset headaches, together with sudden deterioration in neurological function are typical of a sub arachnoid haemorrhage.
The term signature fracture is synonymous with which of the following injuries?
Depressed skull fracture Le Fort II fracture Orbital blow out Oblique fracture of the tibia Supracondylar fracture
Signature fractures are synonymous with depressed skull fractures, they are usually low velocity injuries where the fracture impression resembles the injurious source.
Which of the following is not a form of primary brain injury?
Sub dural haemorrhage after being hit in the head with a hammer Meningitis resulting from infected CSF rhinorrhoea after a basal skull fracture A truck driver is involved in a road traffic accident and suffers an axonal stretch injury A man is hit with a baseball bat and suffers a cerebral contusion A man suffers an intraparenchymal haemorrhage after being hit in head during a car crash
Meningitis resulting from infected CSF rhinorrhoea after a basal skull fracture
Primary brain damage occurs at the point of injury. It includes contusions and diffuse axonal injury. Non reversible.
Secondary brain damage occurs after the injury. Complications include:
1. Haemorrhage
2. Meningitis
3. Herniation
4. Hypoxia
5. Oedema
6. Arterial damage: internal carotid, vertebral artery common
